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Exploring unwarranted variation through the RightCare programme

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The NHS RightCare programme is driven by the wish to reduce unwarranted variation and redirect resources towards better-quality care. It prompts nurses to take control and lead change


While some of the variation in care observed in England is normal and expected, much of it is ‘unwarranted’ and cannot be explained – or indeed defended. Unwarranted variation wastes valuable resources, is a symbol of poor-quality care and leads to poorer outcomes and experiences for individuals and populations. One of the principles of the NHS RightCare programme is to search for and reduce unwarranted variation, and nurses are ideally positioned to lead this search and take action to improve care. This article offers an introduction to unwarranted variation and discusses how nurses can tackle it through the RightCare programme. It is published in parallel with an example of how RightCare is used in Liverpool to engage general practice nurses.

Citation: DaSilva P et al (2018) Exploring unwarranted variation through the RightCare programme. Nursing Times [online]; 114: 1, 28-30.

Authors: Philip DaSilva is co-founder and clinical advisor, NHS RightCare; Michelle Mello is NHS RightCare national clinical lead for shared decision making; Susan Aitkinhead is director of nursing, professional development; all at NHS England.


NHS England is rolling out RightCare, a national transformation programme committed to delivering the best care to patients, making the NHS’s money go as far as possible and improving patient outcomes. The RightCare programme uses evidence to design practical support aimed at helping local healthcare organisations understand how and where money is spent, and how to use their resources to deliver optimal care for patients.

A fundamental principle of RightCare is to search for and reduce unwarranted variation – that is, variation in the way services and care are delivered that cannot be explained by differences in patient illness or patient preferences and offers no improvement in outcomes or experiences for individuals or populations.

Nurses have a key role to play in the RightCare programme, as the nursing profession has the privilege of having greater insight into the needs of individuals and communities than other professions in healthcare. This article offers an introduction to unwarranted variation and discusses how nurses can help reduce it.

Transformation in the NHS

All nurses have a leadership role in driving quality improvements. As changes in the health and care landscape influence our understanding of health, wellbeing and the types of care required by our diverse populations, we also understand that the biggest threat to our capacity to deliver good-quality services is resources, and that this will mean transforming the way we plan and provide care. It is important that nurses at all levels reflect on their unique position and on how they use the available resources to deliver high-quality care.

Transformation – a process of continual improvement and redesign to improve patient outcomes, system performance and professional development, as set out in the Five Year Forward View (NHS England, 2014) – is necessary so we have health and care services that are fit for today and adaptable in the future. We recognise that we cannot rely on traditional solutions to some of the major pressures we are facing, and that we need to think differently and use our leadership knowledge and skills to narrow the gaps in health and wellbeing, care and quality, and funding and efficiency. Nurses can only demonstrate the extra dimension and value of their work if they draw on their leadership qualities to measure the outcomes and use of resources involved in their work.

Nurses – indeed all clinicians – must be accountable for the resources they use and more aware of how those resources are being used to provide care. We must focus more on the way individuals and populations can both access and receive care.

A good place to start is to identify and address unwarranted variation in the way care is being provided. Once we can see where care inequalities exist, we can start exploring the reasons for these inequalities and do something to reduce them, so that everyone can receive the highest standards of care with the available resources.

What do we mean by variation?

The different ways services are organised and care is delivered in the NHS across England have been debated for countless years. Interest is heightened when some models of care delivery provide better outcomes or experiences than others. It can be a struggle for clinicians to explain why those variations occur and persist.

Variation is often described as being either ‘warranted’ or ‘unwarranted’. Not all variation in healthcare is bad – some is inevitable, some is random and some we have no control over. Variation can be an outcome of innovation, as new solutions and models are being introduced. That type of variation, which is expected and normal, is therefore called warranted. It can be described as differences in care provision that reflect factors such as patient preferences, innovation in person-centred care and clinical responsiveness.

The other type of variation, which needs to be considered separately and is more of a challenge, is unwarranted variation. This is defined as variation in the way care is provided that cannot be explained by differences in patient illness or patient preferences and offers no improvement in outcomes. Unwarranted variation is seen as unacceptable, as it not only wastes valuable resources and duplicates work for clinicians, but also offers lower-value care to patients and is a symbol of poor-quality care.

More than just a buzz word

It has been suggested that variation is just a new buzz word that will be gone in a few months’ time. The reality is that variation in healthcare is not a new phenomenon. Unwarranted variation has been highlighted as an issue for more than 50 years, and evidence shows that it remains endemic in the NHS across England.

In the past 50 years, important research has highlighted the existence of variation (Appleby et al, 2011), that research continues. The Atlas of Variation series, started by the RightCare team in 2010, reveals stark variation in the NHS across England. The different compendiums and themed atlases present, in the form of maps and text, routinely available data that can be triangulated with other data to stimulate the search for unwarranted variation and act as a catalyst to releasing resources that can be reinvested.

What drives RightCare

The RightCare team has harnessed the concept of variation to stimulate the search for unwarranted variation. The RightCare programme prompts health professionals to explore and understand differences in care – such as costs, activities or outcomes – that cannot be explained by individual health needs and do not improve outcomes. These differences often result from clinicians, managers or whole organisations simply doing things based on historical patterns of care and local preferences.

As explained above, there can be good reasons why health and care outcomes may vary. However, most of the observed variation is unwarranted, and unwarranted variation is wasteful and a symbol of poor quality, so we should change it if we can. This is what drives the RightCare programme, and it has also been set out in Leading Change, Adding Value: A national framework for nursing, midwifery and care staff (NHS England, 2016).

Leading Change, Adding Value was launched in May 2016 to help nurses, midwives and care staff achieve:

  • The best quality of experience for patients and people;
  • The best health and wellbeing outcomes for our populations;
  • The best use of finite resources.

The framework, underpinned by 10 commitments developed by staff and people who use and care about health and care services, promotes the search for, and the reduction of, unwarranted variation.

Shift in thinking

Many nurses will consider, quite rightly, that the care they provide is always of a high quality, and there are indeed many examples of excellent care being delivered every day. However, we also know that some care provided is not optimal, often as a result of historical patterns of care. Now is the time to explore and identify those areas and take the necessary action to maximise the use of resources.

This new focus requires a shared understanding and confidence to explore differences in the way care is provided and how resources can be locked up in traditional ways of working. A shift in thinking is needed so that we think about not only how we address the needs of the individuals and populations we care for, but also how we are using our resources (which, alongside available funding, include our skills, experience, knowledge and time) and how we commit to use all those resources to deliver optimal care.

Some nurses may consider that variation is none of their business and that nursing is simply about delivering good care to the person in front of them. A lot of the time, that is correct. However, many nurses also rightly question why some services work differently than others: is this due to the style of the person leading care or because of the way evidence is being applied? By using the power of variation and reflecting on those differences in care models and outcomes, we have an opportunity to ask ourselves: does this variation present an opportunity to improve care?

Three steps to identify variation

A good place to start is to explore how and where resources are being used in our respective workplaces. Help is at hand through the RightCare programme, which shares many examples of care settings that have made a successful start with the programme.

The RightCare team has developed a methodology showing how to use available data to inform decisions about the health needs of populations, and how and where money should be invested to achieve the best outcomes. RightCare is simple to use and helps nurses through a clear three-step process toward better decision making. These three steps to help identify and reduce unwarranted variation are outlined in Box 1.

Box 1. Three steps to help identify and reduce unwarranted variation

Step 1 – Where to look. Step 1 uses robust data to identify clinical areas where there is the biggest opportunity to improve experiences and outcomes for individuals and populations

Step 2 – What to change. Step 2 uses the data and supporting evidence to design optimal care pathways to improve experiences and outcomes. This is where clinicians are key and nurses are at the forefront, leading the change

Step 3 – How to change. In Step 3, clinicians including nurses hold themselves and others to account for the delivery of optimal care through the newly agreed pathways. They work together to maximise their contribution and avoid slipping back into old ways of providing care. This is the only way to ensure changes will become embedded and the use of resources will be maximised to fully benefit individuals and populations

Example of stroke care

As an example, we can look at an area where we already know that there are large variations in the way services are provided in the NHS in England – stroke care. We can look at how our stroke services differ and ask ourselves:

  • How much do we spend on stroke care?
  • Is the best care provided in Northampton, Nottingham or Newcastle? Or is care equitable across England?
  • How much do we allocate to stroke prevention?
  • How many hospital admissions for stroke care did we have last year?
  • What were the outcomes for those individuals?
  • How much waste and duplication is there in our local system?
  • How can we release funds and direct them to better-value care?
  • Perhaps the most important question – why don’t we know these things?

These types of questions can stimulate us to understand some of the reasons for unwarranted variation in stroke care, and also help us to take steps to reduce it at a local level.

An ideal role for nurses

Nurses spend more time with patients and their families than other health professionals, and have both the understanding and skills to adjust care to changing needs. This is an essential part of nurses’ daily work and it makes the profession central to improving outcomes and experiences for individuals or populations. Nurses have a leadership role that they should embrace and celebrate. Key areas of nurse leadership are outlined in Box 2.

Box 2. Key areas where nurses have a leadership role

  • Focusing on quality and outcomes as well as finance and use of resources
  • Creating the right culture and relationship building
  • Actively engaging in the Sustainability and Transformation Partnership (STP) programme
  • Directing all clinical initiatives so the focus is on value and outcomes
  • Making the RightCare programme ‘business as usual’
  • Using Leading Change, Adding Value to demonstrate achievements and contributions on a global scale

Nurses are therefore in a unique position to explore and address variations in care that add no value to the health of individuals or populations. They can contribute to the search for, and reduction of, unwarranted variation, and lead the process to ensure all resources are used towards delivering high-quality care. The longer unwarranted variation remains unchecked, the longer the nursing profession misses the opportunity to provide optimal care by directing resources to where there will be the greatest gains.


Nurses are central to delivering effective and compassionate care as well as to improving health outcomes. The nursing profession is therefore ideally placed to build on the RightCare programme, search for unwarranted variation and lead the changes required to release resources for better outcomes. By adopting the RightCare programme, nurses have an opportunity to harness the power of variation and demonstrate the contribution of the profession in delivering effective change, both nationally and internationally, as we move towards 2020 and beyond. 

Talking points

  • NHS England is rolling out the RightCare programme, which is driven by the aim to reduce unwarranted variation
  • Unwarranted variation is a waste of resources and a symbol of poor-quality care
  • All nurses have a leadership role in driving quality improvements
  • Nurses have a key role to play in the RightCare programme using their leadership skills
  • Nurses need to think about how resources are used and explore unwarranted variation
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